NURS 4311 Advanced Care Planning

Patient Self Determination Act (1991)

Federal legislation enacted December 1, 1991, establishing requirements for healthcare facilities to educate on the rights of advanced directives

Inform: Educate patients about advance directive rights

Inquire: Ask if patients have existing directives

Do Not Discriminate: Cannot withhold care based on directives

Ensure: Document the presence or absence of directives

Provide: Supply information about advance directives

Advance Directives

Legal documents that outline a patient's healthcare preferences, medical treatment choices, and instructions for care when the patient is unable to communicate for themselves

Advanced directives

Must be on file with healthcare provider

some states might need it notarized

General Power of Attorney

A document granting legal and financial decision-making authority that ends if the patient becomes incapacitated,

They can do ANYTHING in your name like even buying a car or a home

Medical Power of Attorney (MPOA)

a person who is chosen to communicate with providers, access medical records, and make medical treatment decisions when a patient is unable to do so

Directives to physcian and family (living will)

Decide treatments you want or refuse

Discuss with family, clergy, or friends

Complete the formal document

when are these types of wills / directives made

when person is of sound mind and body (before they are sick)

DNR Order

A physician-signed medical instruction directing healthcare providers to withhold cardiopulmonary resuscitation (CPR).

Out-of-Hospital DNR

A document signed by patient and physician instructing EMS to withhold CPR outside of a hospital setting;

It is valid with EMS only, does not apply during hospital admission, and does not prevent comfort care.

Out of hospital DNR

must be signed by physician and patient

Physician Orders for Life-Sustaining Treatment (POLST)

A voluntary medical order created after discussion with a provider that translates patient preferences into actionable medical instructions regarding CPR, ventilators, antibiotics, nutrition, and comfort care for seriously ill or frail patients.

RN Role: Educators

The nursing responsibility to provide clear, accessible explanations about living wills, DPOAHC, and DNR/DNI options to ensure patient wishes are honored when incapacitated.

RN Role: Facilitators

The nursing responsibility to initiate discussions about values, beliefs, and goals of care, especially when physicians are unavailable.

Create a safe space for sharing

RN Role: Advocates

The nursing function of supporting patient autonomy and ensuring that advance directives are properly documented, accessible, and honored.

RN role: Navigate

The ANA Code of Ethics mandates that nurses promote advance care planning and respect patient self- determination. Nurses must stay informed about state- specific laws and terminology

RN Role: Assessors

The nursing function of determining whether advance directives exist, confirming they are current and reflect patient wishes, and prompting updates when appropriate.

ANA Code of Ethics (ACP Mandate)

Professional standard mandating that nurses actively promote advance care planning and respect patient self-determination while staying informed on state-specific legal requirements.

Practical tips of advanced care planning

These evidence-based practices help nurses effectively support advance care planning conversations while maintaining therapeutic relationships with patients and families.

Start early—begin ACP discussions before crisis

Use clear, jargon-free language with all patients

Be culturally sensitive and respect diverse beliefs

Document thoroughly and place directives in chart

Culturally sensitive discussions

Effective advance care planning requires empathy, cultural awareness, and respect for diverse values. Before conversations, reflect on your own cultural biases and assumptions.

Emphasize empathy and respect for all values

Reflect on personal cultural biases

Practice mindfulness before conversations

Respectful practice steps

When supporting patients through advance care planning, nurses can create space for authentic decision-making while honoring cultural identity.

Explain advance directives clearly without pressure

Collaborate with chaplains, cultural brokers, community leaders

Include cultural preferences in the care plan- document

Communicate preferences to the full care team

Decision-Making Capacity

patient's ability to receive information, evaluate and deliberate options, and communicate clear treatment preferences

Common misconception

Only elderly or terminally ill people need advance directives

A lawyer is required to create an advance directive - boils down to state laws

A lawyer is required to create an advance directive

Naming an agent means loss of control

Living will covers everything

Once done, file and forget